Healthcare fraud by organized criminals is back in the news, with reports focused on jaw-dropping losses to government and private programs and advice for payers to combat this threat.
Konstantin Grigoryan, for instance, was charged with stealing doctors' identities in a $20 million Medicare fraud scam run by a Russian-Armenian crime ring, Security Intelligence reported. Criminals recruited patients for unnecessary services and tried to cover the crime by creating fake test results.
After the rocky rollout of the Affordable Care Act's enrollment site HealthCare.gov, organized criminals began bombarding the public with emails and phone calls in an effort to steal identities. "Buggy systems," the article noted, "often provide criminals [with] the opportunity to exploit glitches to gain unauthorized access, read data and even modify code executed during subsequent user sessions."
And Peyman Heidary, a California chiropractor known as "The Godfather," stands accused of orchestrating a $50 million insurance fraud, The Press-Enterprise reported. Heidary is an alleged crime boss who set up medical clinics that reportedly cheated 23 worker's compensation payers, law enforcement officials told the newspaper.
Organized crime syndicates--including Albanian, Italian, Mexican and Russian crime families--continue targeting insurers in part due to the difficulty in developing cases against them, according to Security Intelligence. Investigative obstacles may include lack of IT resources, challenges of quantifying return on anti-fraud investments, acquiring and integrating data and certain regulatory requirements. Consequently, "many crime rings are able to stay under the radar for years," the article noted.
To fight fraud by organized crime, insurers should watch global market trends that drive claims spikes. Increased demand for scrap metal overseas, for example, can lead to more staged auto accident claims. And these often accompany healthcare fraud, Security Intelligence reported.
"Many [organized crime fraud] schemes are difficult to unravel and require extensive federal investigation," Department of Justice attorney Rebecca Pyne told FierceHealthPayer: AntiFraud in an exclusive interview. "Watch for unusual claims or provider conduct, and train employees to report irregularities they see in billings or in their contacts with patients or providers."
Fraud fighters should also consider using link analysis to expose fraud networks, Security Intelligence added. And "investigators need to be prepared to 'go underground' and maneuver in the deep web marketplaces to position themselves in a proactive state."